Science in the Age of Trump


As Donald Trump seeks to build his administration, he will likely struggle with creating a science infrastructure, given his estrangement from the nation’s scientific community.

The distance between Trump and scientists seems to reflect mutual disdain. Trump famously trusts his gut over more data-driven methods. Trump’s success, against most expectations, can be read as a triumph of instinct over science, or at least to reveal the perils of data-driven overconfidence. Trump’s apparent intention to appoint a climate-change skeptic to lead the environmental protection agency suggests to many a disregard for the vast weight of scientific data here, while his comments about vaccinations during one of the Republican debates were charitably described by Steven Salzberg as “wildly inaccurate” and “thoroughly discredited.”

For their part, most scientists take a very dim view of Trump: Science prides itself on being inclusive, international, objective and collaborative–not generally the first adjectives used to describe Trump. (Whether science in practice lives up to these ideals is another question.) Add to this Trump-specific distaste the left-leaning bias of universities (well documented by centrist academics like Jon Haidt, among others–see here and references therein), and the result is a community that seems solidly united against the President-elect. (That said, I’d note that I’ve met more than a few political independents within academia who chafe at current norms.)

The problem, of course, is that science matters to America and to Americans. The U.S. scientific ecosystem has advanced knowledge and powered a range of industries, from biotech to aerospace. America has a wonderfully robust tradition of supporting scientific exploration, and it’s hardly surprising–but worth noting–how many great scientific advances, including many resulting in Nobel Prizes, were made by researchers originally from other countries attracted to the United States by the freedoms of our nation.

Many Trump critics argue passionately against participating in the Trump Administration, essentially suggesting that joining the team would help legitimize an unworthy (some would say execrable) regime. (In a small, informal and unscientific Twitter poll I did over the weekend, about a quarter of respondents were in this category.)

The alternative view is that in a Trump administration, it’s especially important for rigorous scientists to participate and be heard–provided, of course, that their voices would be heard, rather than their prestige co-opted. Because so few scientific innovators seem to be drawn to the Trump team, those who participate may find themselves–like Silicon Valley VC Peter Thiel – with an opportunity for influence far greater than they would have had in a more traditional administration.

To this end, one name that immediately comes to mind as a potential biomedical advisor or potential appointee is Dr. Jeffrey Flier, who recently stepped down as Dean of Harvard Medical School, after nearly a decade in that role.

(Disclosure: I know Flier as an endocrinologist and colleague, but do not have a personal or business relationship; I do have a long history with the university, including a current adjunct/visiting scientist appointment.)

In addition to deep expertise in medicine and science, and a range of honors including elected membership in the National Academy of Medicine, Flier has three attributes that would presumably appeal to the Trump administration.

First, Flier has encouraged the university to embrace entrepreneurship while remaining true to its academic foundation–an incredibly difficult needle-threading challenge that he somehow seems to have pulled off, a testament to his vision, independent thinking and political aplomb.

Second, Flier’s striver background is arguably similar to Trump’s: on the way to becoming Dean at Harvard, Flier went to City College of New York, and received his MD and subsequent training at Mount Sinai School of Medicine. He rose through the ranks at Harvard’s Beth Israel Hospital, which might be viewed as Boston medicine’s version of coming from the Outer Boroughs (see this Samuel Shem classic for more detail).

Finally, Flier’s love of medicine is clearly part of the family business; his wife is also a professor of medicine at Harvard, his brother as an internist in the Boston area, and his two daughters are physicians as well.

While Flier has suggested on Twitter he has no interest in being considered for a role in the new administration, Trump’s team would do well to do whatever they could to bring him into the fold.

Our nation’s continued leadership in biomedical science is vitally important for our collective future. The new administration must seek to recruit the best talent–even NeverTrumpers, like Flier; similarly those who are tagged–even NeverTrumpers–must consider serving, for the benefit of the country.

from THCB

What Does the Recent Election Mean For Predictive Analytics In Healthcare???


The outcome of the recent election caught many people, and many forecasters, by surprise. How could their predictions have missed the mark so significantly? Granted, there were a number of people who predicted the outcome more accurately, but many of those who used data models to analyze the likely outcome are left now with head-scratching and postmortem analysis in order to improve their methods.

In their book Superforecasting, The Art and Science of Prediction, authors Philip Telock and Dan Gardner describe a subset of people who, on average, are significantly more accurate in their ability to predict upcoming events. “What makes them so good is less what they are than what they do—the hard work of research, the careful thought and self-criticism, the gathering and synthesizing of other perspectives, the granular judgments and relentless updating.”

What does this mean for healthcare? I’m not talking about the impact of the new presidency on health policy and healthcare delivery (that’s another discussion) – I’m talking about whether predictive analytics is really all that accurate in the first place. Where does it fail?

The strengths and weaknesses of predictive analytics

Predictive Analytics in healthcare, a buzzword in the industry for a couple of decades, is the science of determining which populations are likely to become ill, what the health and cost implications of that are, and what might be done by way of pre-illness intervention to change things. About 20% of the population consumes 80% of health care dollars. But those who are catastrophically ill this year are not necessarily the ones who will become catastrophically ill next year – the high-cost cohort, though a consistent finding year after year, will be comprised of different individuals each year. The goal of medical Predictive Analytics is to figure out who will likely drop into that high-cost bucket next year, and what can be done to reduce that risk.

Much of risk stratification (the core of medical Predictive Analytics) is focused on populations. Taking people with certain health risk parameters in aggregate, as a population, is something that is predictable, can be measured and studied, and is the basis of what we have now. But drilling that understanding down to an individual patient becomes much more uncertain. Should this diabetic patient, controlled with medications but not on a statin, and who has at-target LDL cholesterol levels for a diabetic – should this patient be prescribed statins anyway? Doctors will have differing opinions, will do different things, and will look to supporting data (which may be sparse in a more granular analysis) to justify their choices.

How can we get better at individualizing medical recommendations? How can we take the current state of Predictive Analytics, which concerns itself with population management, and move it forward to something more precise?

AI: the next step in prediction

This is where Artificial Intelligence (AI) in healthcare can be very powerful. AI is the intersection of Machine Learning (ML) – a set of self-teaching algorithms that can identify patterns in data without being pre-programmed on what to look for (therefore without “pre-analysis bias”) – and the application of that ML to very large data sets. The shortcoming of medical AI so far is not so much a shortcoming in ML algorithms, but is the lack of very large, normalized data sets on which it can work. Medical data (clinical data) is historically fragmented into institution-centered silos, and claims data is segmented into payer silos. Aggregating this data into huge data sets is the task at hand in order for AI to become meaningful.

From this effort, our Medical Knowledge Graph (MKG) can be extraordinarily useful. The Flow Health Medical Knowledge Graph is the organized result of AI insights built in a way that can be used on-the-fly by a variety of medical applications, such as Electronic Health Records, population management and reporting tools for value-based care, web tools, and patient-facing apps. For the patient described above, the individualized recommendation can be made for that given person, and take into account all the diagnoses, lab values, medications used and discontinued in the past, and genetic markers if known.

Does this technology, once it matures, make the doctor’s role obsolete? No. It makes the doctor’s role more precise, more accurate, more consistent. In clinical medicine, we use clinical judgement based on recognizing a pattern presenting in a given patient, and we try to match that against similar patterns from our learning and our experience. We then use that pattern-matching to make recommendations. In the case of AI and the MKG, the pattern can be described in more detail, and the comparison is done against the entire body of data available to the ML engine. It becomes a tool that can make clinical judgement much better informed.

Predictive analytics, and the AI tools now becoming available, predict the odds of success, or the odds of something occurring. They deal in probabilities. However, as noted by many forecasters, nothing is truly certain (until it happens). Failures of accurate prediction teach the learning engines. This is true in political outcome prediction, and it is true in medicine. Leaders, whether in government, in the military, in business, or in healthcare, need to be well-advised, but must make executive decisions. In healthcare we call that making a surgical decision (there are no erasers on the ends of scalpels). Clinicians need to be decision-makers, informed by the best analytics available. In health IT, we need to build the best analytics engines we can, so as to inform medical decision-making in the best way that technology allows.

Robert Rowley, MD is Chief Medical Officer at FlowHealth

from THCB

One Regulation Could Eliminate a Dozen Others

President-Elect Trump recently announced: “for every one new regulation, two old regulations must be eliminated.” Regulatory capture, the topic of a recent THCB post by Nortin Hadler, has enabled many regulations based on HITECH that restrict competition by allowing information blocking. Many other regulations around quality measures, documentation, decision support, contract transparency, and kickback safe harbors are now needed to counteract EHR vendor consolidation through regulatory capture.

One regulation designed to establish a patient-controlled interface (a patient-controlled API) to health records will enable competition for all aspects of the institutional EHR by decentralizing access to the patient information. The impact on health reform, ACA reform, and medical research would be immense.

“Give me the place to stand, and I shall move the earth.” If Archimedes were moving healthcare practices and politics then data would be his lever. The data to move healthcare is much more than a hospital’s EHR will ever be trusted with. It includes the social determinants of health, it includes employment and exposure, it includes your genome and family, it includes personal beliefs.

The data to move healthcare practices and politics does not split cleanly between research and clinical uses. Sync for Science is not enough to provide independent decision support at the point of care. Access to detailed personal data spanning the full range of human experience and aggregated over a lifetime is now technologically possible. Who can be trusted with this formidable power?

Nobody but ourselves. Regardless of how well-regulated and well-organized our healthcare and government institutions might be (need we review the cybersecurity track record of either hospitals or government?), the only one to be trusted with knowing everything about me is me.

The world is full of institutions and people that know something about me. Some, I know about. The vast majority are hidden data brokers. Surescripts, Acxiom, Lexis-Nexis, Optum, IMS, All Payer Claims Database, and Prescription Drug Monitoring Programs are all collecting and selling as much about me as they can. It’s their only business and I am the product. Even as the patient surveillance industry has boomed along with my out-of-pocket costs, transparency of health care quality or cost is as elusive as ever.

As Doc Searls recently commented: “Economically speaking, the American health care system is not built for patients, because patients aren’t the ones paying for it directly. Insurance companies are.” This well-known technology journalist speaks in favor patient-centered health records.

Technology now makes it possible for each of us to control more and better data than the hospitals and data brokers. That means each of us as patients would have more leverage to move health care and health insurance practices. Instead of buying our information from hospitals and data brokers, our providers, researchers, and regulators would be getting the information by asking us. By asking us.

Which leaves one major contingency: Who would pay to give us patients the ability to control our own health records? A less regulated, more market-driven health system is now technically possible but it requires investment and a sustainability plan. In the long run, patients facing many thousands of dollars in out-of-pocket expenses will see the wisdom of spending a few hundred to inform their spending. More immediately, and aligned with whatever policies a Trump administration brings to health and human services, we might see pharmaceutical companies, insurance companies, and public institutions – anyone that would benefit from better access to patient records in a value-based payment system – invest in patient-centered health records. It all starts with one well-designed regulation to replace information blocking with “Just ask me”.

Adrian Gropper is Chief Privacy Officer of the Privacy Rights Foundation.

from THCB

Asian Chicken Lettuce Wraps

Dinner tonight was awesome! I made these Asian Chicken Lettuce wraps from The Paleo Diabetes Diet Solution cookbook. While I don’t have diabetes and I’m not “paleo”, as you might already know from my latest “10 Things about Me” video, I do love a healthy and tasty recipe. These wraps are blood sugar balancing and very satisfying. I had two and I was perfectly happy. 

Usually I am not a huge fan of recipes with a long list of ingredients, but believe me when I tell you this recipe was worth it! And it wasn’t labour intensive – just a lot of ingredients. I made a few changes based on ingredients I had on hand so I didn’t have to do a whole new grocery shop.

Lucky for me, we have leftovers too. This could easily feed a hungry family. I feel like Walker and I barely made a dent in that bowl!

Asian Chicken Lettuce Wraps-06625

This recipe is gluten-free and dairy-free however as I was eating it I thought to myself this would be really nice with some goat feta sprinkled on top. That would kinda ruin the Asian vibe though seeing as feta isn’t usually in asian dishes. 

Walker said he would have rather had a hard shell taco or fajita with it but I loved the lettuce wrap. My belly is happiest without many grains anyhow, so I was quite pleased with dinner.

Vienna didn’t have any but that’s only because she’s not feeling well right now. She got a head cold about 10 days ago and as soon as it seemed like she was better it morphed into something else. Last night we had to take her to Sick Kids Hospital :( because things escalated but she’s on the mend now. It was pretty scary, I was in tears en route to the hospital but I guess that’s pretty normal when your baby is sick for the first time. Or maybe I’m just a big suck. Probably the latter. :)

Okay let’s get to this tasty and nourishing recipe shall we? 

Asian Chicken Lettuce Wraps
2016-11-28 19:44:28

  1. SAUCE
  2. 2 garlic cloves, minced
  3. 1 tbsp ginger root, minced
  4. 1 tbsp fresh cilantro*, chopped
  5. 1 tbsp sesame seeds
  6. 1/4 cup tamari
  7. 1 tbsp lime juice
  8. 1 tbsp rice vinegar
  9. 1 tsp fish sauce (I omitted this because I didn’t have any)
  10. 1 tsp toasted sesame oil
  11. I added: 1 tsp real maple syrup
  12. STIR-FRY
  13. 1 tbsp olive oil for sautéing
  14. 1lb organic ground chicken
  15. 2 celery stalked, finely chopped
  16. 1 carrot, finely chopped
  17. 1/2 red pepper, finely chopped
  18. 1 cup snap peas (I didn’t have any so I used frozen sweet peas)
  19. 1/2 cup onion (I used red onion) finely chopped
  20. 1 garlic clove, minced
  21. 1/2 cup shiitake mushrooms (I didn’t have any so I used crimini)
  22. 1 tsp ginger root, minced
  23. 2 green onions, chopped
  25. 12 Boston lettuce leaves (I didn’t have any so I used Romaine and turned these into “wraps”. The original recipe is called “cups”)
  26. 1 cup bean sprouts (I used sunflower sprouts)
  27. 1/4 cup fresh cilantro*, chopped
  28. 1/4 cup cashews, toasted and chopped (I just used raw, unsalted)
  1. Sauce: In a small bowl, combine garlic, ginger, cilantro, sesame seeds, tamari, lime juice, vinegar, fish sauce (if using), sesame oil and maple syrup (if using). Set aside.
  2. Stir-fry: In a large skillet, heat olive oil over medium high heat and add chicken and cook until it’s no longer pink. Add celery, carrot, red pepper, peas and onion. Stir fry for a few minutes. Stir in garlic, mushrooms and ginger. Add half the sauce to the pan. Cook for 1-2 more minutes then transfer to a large bowl and top with green onions.
  3. Lettuce wraps: Fill lettuce leaves with stir fry and top with bean sprouts, cilantro and cashews. Drizzle remaining sauce over top as desired.
  4. The next time I make this I will double the sauce ingredients.
  5. ENJOY!
  1. *Hate cilantro? Use parsley instead.
Joyous Health

Asian Chicken Lettuce Wraps-06621

I just love the photo above because just seeing it reminds me of how incredible cilantro smelled. I think someone should make a cilantro perfume? Don’t you think? haha! Okay maybe not but chopping and smelling it makes me feel so gosh dang joyous! Sorry to those who hate cilantro out there, you could  swap it with parsley instead.

I loved that there were so many detox-friendly ingredients in this recipe from cilantro to sprouts to green onions that this recipe could easily 

As sign of a great dinner is looking forward to leftovers the next day and that’s exactly how I’m feeling right now!

Have a joyous rest of your week!



Joy McCarthy

Joy McCarthy is the vibrant Holistic Nutritionist behind Joyous Health. Author of JOYOUS HEALTH: Eat & Live Well without Dieting, professional speaker, nutrition expert on Global’s Morning Show, Faculty Member at Institute of Holistic Nutrition and co-creator of Eat Well Feel Well. Read more…


The post Asian Chicken Lettuce Wraps appeared first on Joyous Health.

from Joyous Health

Why Trump Won? A Brief Tutorial for Harvard Medical Students

Mike Milligan, a Harvard medical student, recently wrote in THCB about the shock felt throughout his medical school upon the election of Donald Trump.  Seeking to understand how it may be that ‘equality, service and compassion’ were defeated, Mike settles on the narrative that appears to have taken hold of the elites on the left – Trump did not really win, Hilary lost.  While he does not say so in explicit terms, clearly we are to understand that the recent election was lost, and that in order to assure a better outcome the next election, physicians should urge their patients, and particularly their ‘poorer and less educated patients’ to register to vote.   Hopefully, these voters can then ensure that access to ‘affordable, high-quality medical care’ through constructs like Obamacare and MACRA are nevermore placed in jeopardy.

What complete hogwash.

Let me start with the factually incorrect parts.

Mike writes that ‘Mr. Trump received fewer votes in victory than the previous two republican nominees garnered in defeat.’  As of today Donald Trump has received 62.2 million votes out of a total of 126.6 million votes cast.  Mitt Romney received 60.9 million votes out of a total of 126.8 million votes, and John Mccain received 59.9 million votes out of a total of 129.4 million votes cast.  So despite the fact that his opponent raised and spent close to 1 billion dollars on ads promising the literal apocalypse if Trump was elected, no republican candidate in history garnered more popular votes than Donald Trump.  While it is true that nearly half of all Americans did not cast a ballot in this election, 3 million more votes were cast in 2016 than were cast in 2012.  The percentage of eligible voters casting their vote in 2012 was 55%.  The percentage of voters casting their vote in 2016?  Also 55%.  I realize the desire to deligitimize Trump by arguing this was a low turnout election that delivers no mandate is a very strong one among the millions on the losing side.  Unfortunately, wishes and reality sometimes find themselves in conflict.

The real story of the election is that the Donald Trump managed to flip the rust belt states of Michigan, Wisconsin and Pennsylvania by convincing blue-collar, mostly white voters that his party was now the “workers’ party”.  Traditionally blue strongholds of towns like Erie, Luzerne, and Northampton counties in Pennsylvania turned red in 2016. A Republican hasn’t won Erie County since 1984!  Obama won this county  by 16 percentage points in 2012 – Trump won this same county by 2 percentage points.  Statewide, Trump performed better than Romney in 58/67 counties while Clinton performed worse than Obama in 65 counties.  So it is absolutely true that Clinton performed worse than Obama, but not to focus on the story of the overperformance by Trump is to be willfully blind.


As to the implication that it was the least educated sitting at home that sunk Mrs. Clinton, data would argue the opposite.  The poorly educated did vote, and by a wide margin chose Trump.  Pre-election polling showed Trump with a 30-percentage point advantage among whites without a college degree – he ended up winning them by 40 points.  Indeed, one of the single best predictors identified in counties that swung to Trump is the percentage of non-college whites.  The greater the percentage of non-college educated whites in your county, the greater the chance of Trump emerging victorious.

The only metric found to be even more predictive than your race and education?  Poor health. You are reading that correctly.  In an analysis done by the Economist , a weighted index of obesity, diabetes, heavy drinking, physical exercise, and life expectancy performed even better than race and education level in predicting counties that moved to Trump.  The poorer your health, the more likely you were to vote for Trump.


A wonderful interactive version of the graph can be found here.

Apparently, those who stood the most to gain from affordable, high quality health care were also most likely to choose the candidate who called for repeal of Obamacare.  It is safe to say that this was a stunning repudiation.  To a great many who had voted for the promise of Obamacare, the reality of high premiums, penalties, and narrow networks left a bitter taste.  And so it came to be that those uneducated and in poor health – the losers in this economy – chose the candidate who promised change over the candidate whose campaign slogan was grabbed from the recent Lego movie – “Everything is Awesome”. What a complete shock.

There are many story lines that underlie Hilary Clinton’s defeat.  She was clearly unable to animate and connect with her base in the way Barack Obama did – but if this is the major narrative rocking liberals to sleep in these cold dark times, I would advise the overworked mental health specialists dealing with the trauma of a Trump election on college campuses to pace themselves for eight years of inconsolable sobbing.

Anish Koka is a cardiologist in Pennsylvania.

from THCB

Holiday Cookies! Fruit and Nut Thins

This year, Chatelaine magazine launched a Holiday Cookie Exchange with a few foodie-obsessed friends like me. I shared a recipe for my Chocolate Chip Tahini cookie, which is a joyous-reader fave! Have you made it? And the Chatelaine kitchen team sent me a recipe to try these “Fruit Thins” from their holiday cookie collection. 

Fruit and Nut Thins-06605

Of course in joyous style, I had to change this recipe just a bit to make it friendly for the joyous community — YOU! The main ingredients I changed were instead of white flour I used spelt flour, instead of sugar I used to maple syrup, instead of butter (I’m not against butter I just wanted to make it as friendly for all dietary choices as possible) I used coconut oil. I also added some more spices like ground ginger and ground cinnamon. In fact, we could easily call these Spicy Fruit and Nut thins.  

Fruit and Nut Thins-06590

I also halved the recipe because it makes 40 cookies and I don’t know what I would do with that many cookies between Walker and Vienna and I — eek. It would be dangerous really! However, the recipe I have included below does make 40 cookies. If you want to make about 20 cookies instead, just divide every ingredient in half. It also makes it a bit easier when you get to the part where you slice the near-frozen batter because you don’t have to cut it crosswise.

Fruit and Nut Thins-06597

These cookies really remind me of skinny biscotti. In fact, you could even bake them a little longer to make them even more like a biscotti-texture if you like!

I have to admit, I was really unsure how these were gonna turn out because I changed ingredients and also changed up the method a bit. They turned out AMAZING and will definitely be on my holiday cookie recipe list for years to come.  

 Just make sure no matter what, you use high-quality ingredients. I went to my local health food store and bought these organic hazelnuts, pistachio’s and sulphite-free cranberries (notice their not bright red). Shopping in bulk for these type of ingredients is a cheaper way to buy organic. Note: hazelnuts are pretty damn expensive, so feel free to swap with raw almonds instead :)

Fruit and Nut Thins-06585

 Be sure to scroll all the way down to see 5 more cookie recipes!

Holiday Cookie: Fruit and Nut Thins
2016-11-26 17:07:36

  1. 1 3/4 cup spelt or kamut flour
  2. 1 tsp baking soda
  3. 1 tsp ground cardamom
  4. 1 tsp ground cinnamon
  5. 1/2 tsp ground ginger
  6. Pinch of fine sea salt
  7. 1/3 cup water
  8. 3/4 cup maple syrup (There is quite a bit more sugar in the original recipe)
  9. 1/2 cup melted organic butter or melted coconut oil (I used coconut oil)
  10. 1/2 cup shelled pistachios, coarsely chopped
  11. 1/2 cup roasted hazelnuts, coarsely chopped (original recipe says to peel them but I didn’t — I was being lazy)
  12. 1/3 cup unsulfured dried cranberries
  13. Optional: 1/2 cup orange peel (You could just use a cheese grater to get the zest from the orange)
  1. Preheat oven to 350F.
  2. Line an 8 × 4-in. loaf pan with plastic wrap.
  3. In a large bowl, combine flour, baking soda, spices and fine sea salt.
  4. In a separate bowl, combine water, maple syrup, melted coconut oil, nuts and cranberries.
  5. Add the wet ingredients to the dry and mix until just combined.
  6. Place into the loaf pan you lined with a large piece of plastic wrap. Press the mixture down and make sure it’s covered by the wrap. Freeze batter for 2 hours.
  7. After 2 hours, remove batter from the freezer. If you did NOT half the recipe, then you’ll have to cut the batter into half crosswise (I know.. that sounds confusing, but you’ll know what I mean once you make it). And then slice each cookie about 1/3 of an inch thick.
  8. Line a cookie sheet with parchment paper and place cookies on sheet.
  9. Bake for 12-15 minutes until golden brown.
  1. Makes 40 cookies. As per my notes above, I divided every single ingredient into half because 40 cookies would just be asking for trouble in my home, ha! Dividing some ingredients in half like the flour was a super odd measurement so I just ballparked it and it turned out perfect, so don’t stress about it being 100% accurate.
  2. By the way, taste the batter to make sure it’s sweet enough to your likely. I significantly reduced the amount of sugar.
Joyous Health

By the way, I will be participating in Chatelaine’s Facebook Live on Wednesday November 30, 6:00 p.m. at Chatelaine’s holiday party. I will be sharing cookie tips and tricks with the editors and tasting all the sweet treats. Be sure to watch! 

Since it’s the season for all things cookies, I’ve linked some more of my favourite holiday cookie recipes below for you.

Gluten-free Raspberry Jam Cookies

Raspberry Jam Cookies

Healthy Digestive Cookies

 Digestive Cookies

Gluten-free Chocolate Chip Quinoa Cookies

 Gluten-Free Quinoa Cookies

Good Day Breakfast Cookies

Good Day Cookies-2

Chocolate Breakfast Bark (but you can eat it anytime of day!)

Breakfast Chocolate Bark-04606

Happy Holidays!



Joy McCarthy

Joy McCarthy is the vibrant Holistic Nutritionist behind Joyous Health. Author of JOYOUS HEALTH: Eat & Live Well without Dieting, professional speaker, nutrition expert on Global’s Morning Show, Faculty Member at Institute of Holistic Nutrition and co-creator of Eat Well Feel Well. Read more…

The post Holiday Cookies! Fruit and Nut Thins appeared first on Joyous Health.

from Joyous Health

The Uncertainty Bomb


I like certainty and routine. I like my daily Tall Dark Roast with no room for cream at 5 am at Starbucks. I like the same restaurants, the same suits and ties and the same TV shows. Holidays throw me off and I get bored quickly when I have down time.

For six years, the healthcare industry in the U.S. has been adjusting to its new normal based on the regulatory framework of the Affordable Care Act (ACA). It became routine to discuss the volume to value, accountable care organizations, bundled payments, Medicaid expansion and We were certain they’d be around for years to come.

Then came the election. When 61 million voters elected Donald Trump to the White House and kept GOP majorities in both houses of Congress, it signaled our routines in healthcare would be disrupted. The campaign promised to repeal and replace the ACA: its repeal appears certain but it’s replacement injects uncertainty into our routines around a number of meaty issues:

  • Senate Composition: The mechanisms for replacing key elements of the law will require a super majority of 60 in the Senate: will the 52 GOP senators broker support from 8 Dems for weighty items like how Medicaid block grants could work, how consumers could buy insurance across state lines, how tax credits would work as individuals replace employers as the key insurance market, the potential for vouchering Medicare and much more. How the Senate advances the ACA’s replacement will be a protracted process with many moving parts and considerable political deal making.
  • Federal Budget: Healthcare spending by the federal government is 30% of its total spending. The tension between budget hawks in Congress who fear escalating deficits and the Trump team’s promise to invest $550 billion in infrastructure including hospital improvements will require deft political craftsmanship. Funding for healthcare will compete against pressures to reduce federal spending pitting it against education, transportation, homeland security and defense for budget consideration. And GOP partisans vow cuts to healthcare spending which, in some cases, are at odds with Trump campaign promises.
  • Health Insurance: Creating a new regulatory framework for private health insurance will be complex and time-consuming. Uncertainty about the individual insurance market is particular unsettling and the future of marketplaces unknown. Will the new administration ease restrictions on private insurers that result in higher premiums? Will the individual and employer mandates that are repealed be replaced by other mechanisms that induce coverage and spread risks? Will the shift of financial risk and affordability to providers from insurers accelerate the growth of integrated health systems that operate hospitals, sponsor health plans and networks of clinicians? There are 106 of these today: is integration of financing and delivery the future? And what’s to become of the 21 million who gained insurance coverage through the ACA, including the 12 million who expect to get subsidies to pay their premiums (estimated at $43 billion this year).
  • Consolidation: What’s the future for industry consolidation? Will FTC recent constraints on health system consolidation in Pennsylvania and Chicago be sustained or revisited as appointments to key posts in the Department of Justice and FTC are made. What’s the view of the new administration toward mega-mergers like CHI-Dignity Health, Aetna-Humana and Anthem-Cigna to name a few.  And will the Trump affinity for  free market competition lead to mega-players akin to other industries like banking where five organizations control 45% of assets nationally, airlines where 4 carriers control 80% of passenger miles flown?
  • Veterans Health et al: And how will the new administration orchestrate pledged improvements in veteran’s health, lower drug prices, protection of Medicare, trade agreements and tax reforms that impact U.S. drug and device manufacturers that operate globally and much more?

Answers to these are unknown. And they’ll not be found overnight. That’s the new, new normal. Uncertainty.

Most healthcare organizations put their 2017 Strategic Plans to bed before the election. Capital and operating budgets are already in place as by-products of their planning effort. Each is based on assumptions that carry a high level of certainty.  The election results changed things for many.

The new, new normal in U.S. healthcare is about navigating uncertainty.

For drug and device companies, the news is mostly good. Though the 12 nation Trans Pacific Partnership trade deal appears dead and the Trump campaign railed against drug prices, price controls appear unlikely.  The elimination of excise taxes on medical devices and mandated discounts for prescription drugs appear likely. The administration is likely to focus on streamlining the FDA’s approval process to create more competition which could take years. That’s the reason their stocks in these sectors have gained 10% since the election.

Ditto good news for the health insurance industry. Repeal of the ACA means onerous requirements like essential health benefits and premium increase constraints go away. They’ll benefit from greater flexibility in setting premiums and benefits design. No doubt, they’ll negotiate around guaranteed issue and risk-ratings to strengthen their bargaining position. The marketplaces will be auctioned off to the states, and commissions will be created to define a path forward for private coverage just in time for the 2018 elections. All in all, good news.

For health information technology companies, the news is mixed: there’s no evidence meaningful use will be suspended at last through Stage Two since its funding is outside the ACA, but fear that hospitals and physicians might pull back investing in HIT given mounting uncertainties is evident. Digital health and telemedicine sectors are the exception as the healthiest hospital systems advance their care coordination and population health management efforts but solution providers in both sectors are plenteous and standards around privacy and security risks a work in process.

But for providers, especially hospitals, the election outcome is particularly unsettling. As insurers gain leverage and employers press for lower costs, they’ll hammer physicians, hospitals and post-acute providers for steeper discounts. Medicare’s path will be an unknown for a while: will the GOP successfully orchestrate its transition to a premium support model? Will its mandated bundled payment and value-based purchasing programs carry over as a new CMS team steps in? As Medicaid is transferred back to the states via block grants, will providers be commoditized by the private Medicaid managed care organizations currently used in 39 states to keep costs/beneficiary low? For physicians, MACRA isn’t likely to go away: the election assures that at least 90% of eligible physicians will simply opt for its lower risk MIPS payment model until the dust settles around alternative payment programs like ACOs. Thus, for all providers, uncertainty is reality. And for hospitals, the uncertainty is precautionary.

In most hospitals, boards and management are meeting to revisit their 2017 plans in light of the election results. Like early-stage prostate cancer for men, watchful waiting is a reasonable response to the new, new normal. Uncertainty can be debilitating but a few things are clear:

The certainty of escalating cost pressure. Operating margins for hospitals will shrink faster than anticipated. The potential suspension of insurance coverage for 21 million newly insured means increased bad debt for hospitals. That’s reality. Scale and scope need fresh attention: affiliations and partnerships make more sense now than ever. And cost reduction efforts will take center stage beyond the bread and butter punch list promoted by most consultancies– supply chain improvements, workforce productivity, capital costs for bricks, sticks and technology, and formulary design. Clinical process redesign will be first and foremost: a recent Truven analysis showed savings of $400 per admission in cardiology, gastroenterology and other key programs that are designed around efficiency and effectiveness—more than savings in formulary design and other staples in cost reduction. These expanded hospital cost reduction efforts will necessitate attention to medical practice operational performance since one in three physicians is now a hospital employee and compliance risk mitigation to avoid penalties for safety lapses, avoidable errors and suboptimal outcomes. Add cost effectiveness in data capture necessary to quality, safety and costs, rationalizing of health information technology investments, surgical precision in the design of health insurance benefits for hospital employees and openness to outsourcing virtually every function where efficiency and effectiveness gains can be realized—that’s the widening domain of hospital cost reduction. And it’s certain to be a priority.

The imperative of physician leadership. Physicians aren’t happy. The majority in their ranks believe the health system is deteriorating as their clinical autonomy is challenged and incomes threatened. Being an employee of a large medical group or hospital is not a desired end-game for many but remaining independent seems a pipe dream to most. And the complexity of clinical practice—adherence to evidence, measuring and monitoring outcomes and patient experiences, engaging peers in care coordination, converging behavioral, physical and alternative health disciplines in diagnostics and treatment planning, and acclimating to person-centered care that’s transparent—is daunting. Hospitals bear the brunt of these understandable feelings: they’re intense. Effective physician leadership will be imperative in every sector of healthcare as the new, new normal unfolds. It requires business savvy that compliments clinical training: as financial pressures mount and regulatory expectations change, understanding creation of and access to capital, compliance risks, workforce performance, and day to day operations will be as important as acumen in understanding signs, symptoms, risk factors and co-morbidities. System-building is the future: that’s certain. And those activities, programs, investments, relationships and business interests will revolve around capable physician leadership and financing and delivery are fully integrated.

The centrality of person-centered services. Individuals in every stage of health are the most important stakeholder in the new, new normal. Patient-centered care is limiting: it conveys a paternalistic demeanor toward individuals lending to widespread variability in access, costs and outcomes. It’s limited to inpatient and outpatient services delivered by providers to patients. That’s not the future. Employers are pushing away from conventional coverage forcing employees into high deductible plans. Social media and digital health are providing meaningful comparisons of providers, drugs and plans conveniently and credibly. Health is being defined more broadly around concepts of wellbeing in which social determinants and community programs matter. Alternative health, retail services, telemedicine and online services are as critical in the new, new normal as beds and clinics. Healthcare organizations that default to traditional views of individuals as patients and enrollees risk a growing opportunity for growth and innovation. Transparency in interacting with individuals will be more important than ever: the unintended consequence of Campaign 2016 is widespread public disillusion with established institutions and suspicion about “fake news”.  That’s the reality of the new, new normal.

The election 12 days ago assures uncertainty in U.S. healthcare. Across our system, the unknowns outweigh the knowns. The new, new normal need not be paralyzing: it presents new opportunities for organizations that adapt.


P.S. The election surprised many. In this Thanksgiving season, we should celebrate a system where our periodic political campaigns are the basis for the governing of our Republic. Regardless of the outcome, we live in a system that’s imperfect but still “of the people”.

from THCB